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Coverpage
November-December 2022
Volume 70 | Issue 6
Page Nos. 2339-2471

Online since Monday, December 19, 2022

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NI FEATURE: THE FIRST IMPRESSION  

The Pre-Sigmoid Posterior Petrosectomy Approach for Skull Base Meningiomas Highly accessed article p. 2339
Sandeep Kandregula, Bharat Guthikonda
DOI:10.4103/0028-3886.364082  
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EDITORIAL Top

Management of Arteriovenous Malformations – A Sisyphean Task? p. 2340
Dwarakanath Srinivas
DOI:10.4103/0028-3886.364081  
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REVIEW ARTICLE Top

Timing of Surgery for Ruptured Arteriovenous Malformations with Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis p. 2343
Varun Aggarwal, Seema Rohilla, Ishwar Singh, Vardan Pandey, Gopal Krishna
DOI:10.4103/0028-3886.364074  
Background: Both early surgery and delayed surgery of ruptured arteriovenous malformation (AVM) with intracerebral hemorrhages have their own advantages and disadvantages. Due to lack of large case–control studies, timing of surgery for ruptured AVM excision is still a controversial topic. So, we did a systemic review and meta-analysis, including our experience of early surgery, to see which surgical strategy has a favorable outcome. Materials and Methods: We systematically searched several databases and journals to screen eligible studies. After synthesizing data, results of individual studies of early and delayed surgery were calculated as the effect size (ES) and 95% confident intervals (CIs), and the pooled ES was calculated using random-effects model. Heterogeneity and publication bias were assessed for the individual outcomes. Results: A total of nine published studies, one oral presentation, and our unpublished study were included in the analysis. Delayed surgery has better results than early surgery in terms of complete excision rate (delayed ES, 1.00; 95% CI, 0.97 1.00 vs. early ES, 0.96; 95% CI, 0.91 0.99), good functional outcome (delayed ES, 0.94; 95% CI, 0.86 0.99 vs. early ES, 0.68; 95% CI, 0.51 0.84), and mortality (delayed ES, 0.00; 95% CI, 0.00 0.01 vs. early ES, 0.04; 95% CI, 0.01 0.10). Heterogeneity was significant in the results of early surgery group, and no publication bias was found in the meta-analysis. Conclusion: Delayed surgery is superior to early surgery in achieving higher complete excision rate, good functional outcome, and reducing mortality. However, larger comparative studies are needed for subgroup analysis and for reducing the impact of various confounding factors.
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OPERATIVE NUANCES STEP BY STEP (VIDEO SECTION) Top

Microsurgical Clipping of the Ruptured Meatal Segment Anterior Inferior Cerebellar Artery Aneurysm p. 2350
Sanjeev Kumar, Satya N Madhariya, Chandra D Sahu
DOI:10.4103/0028-3886.364077  
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Resection of Cervical Intramedullary Ependymoma Under D-Wave and SSEP/MEP Monitoring without the Use of Coagulation p. 2354
Harsh Deora
DOI:10.4103/0028-3886.364079  
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ORIGINAL ARTICLES Top

Changes in Sinonasal and Overall Quality of Life Following Endoscopic Endonasal Surgery for Non-functioning Pituitary Adenomas: Results of A Prospective Observational Study p. 2357
Akhil Sunil, Sumit Thakar, Saritha Aryan, Alangar S Hegde
DOI:10.4103/0028-3886.364068  
Introduction: Quality of life (QOL) assessment is increasingly being recognized as an important parameter while evaluating outcomes after endoscopic endonasal transsphenoidal surgery (EETS). There has been no study that has evaluated this in the Indian context. Objectives: We aimed to analyze sinonasal and overall QOL before and after EETS for non-functioning pituitary adenomas (NFPAs), and to evaluate possible correlations between changes in QOL and various clinicoradiological, hormonal, and surgical factors. Methods: This prospective observational study included 62 patients who underwent EETS for NFPAs. The Anterior Skull Base Nasal Inventory-12 (ASK-12) and Short Form-12 (SF-12) were used to assess QOL. Changes in QOL were recorded at 2 weeks, 3 months, and 1-year follow-up periods. Results: While the nasal crusting and nasal discharge components of the ASK-12 worsened 2 weeks after EETS, the headache component demonstrated significant improvement (P < 0.05). The overall ASK-12 score (6.69+/−7.98) did not change significantly at follow-up. The SF-12 physical component summary (PCS) score (42.14+/−8.54) improved progressively after surgery, while the SF-12 mental component summary (MCS) score (42.48+/−7.95) improved 1 year later. The SF-12 PCS correlated with visual field improvement at 3-month follow-up (P = 0.04). Conclusions: EETS affects some components of the ASK-12 without affecting the overall sinonasal QOL in patients with NFPAs. These patients demonstrate progressive postoperative improvement in physical well-being, while their mental functioning improves only a year later. Improvement in physical functioning correlates with visual field improvement at a 3-month follow-up. Hormonal dysfunction and surgical factors do not have any impact on QOL in these patients.
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Can Lamina Cribrosa Indicate Optic Neuritis in Multiple Sclerosis? p. 2366
Mehmet Hamamci, Bekir Küçük, Seray A Bayhan, Hasan A Bayhan, Levent E İnan
DOI:10.4103/0028-3886.364057  
Background: In this study, we aimed to evaluate the association of lamina cribrosa thickness (LCT) and lamina cribrosa depth (LCD), as determined by spectral domain optical coherence tomography (SD-OCT), with visual evoked potentials (VEPs) in patients with multiple sclerosis (MS). Materials and Methods: Patients enrolled in this prospective, cross-sectional study were divided into three groups. Group 1 consisted of 25 relapsing-remitting MS patients with VEP pathology in one or both eyes. In patients with VEP pathology in both eyes, one eye was chosen randomly. Group 2 comprised 25 relapsing-remitting MS patients with no VEP pathology or optic neuritis history. A randomly selected single eye of each patient was evaluated. Group 3 consisted of 25 age- and sex-matched healthy volunteers; a randomly selected single eye of these participants was examined. LCT, LCD, and retinal nerve fiber layer (RNFL) thickness measurements were determined in four quadrants (superior, inferior, nasal, and temporal) by SD-OCT. Results: The three groups were similar in terms of age and sex. The mean LCT was lower in Group 1 than in Group 2, but the difference was not statistically significant (268.80 ± 36.69 μm [min-max = 222-394 μm] versus 285.80 ± 12.00 μm [min-max = 249-338 μm]; P = 0.148). The mean LCT was significantly lower in Group 1 than in Group 3 (268.80 ± 36.69 μm [min-max = 222-394 μm] versus 294.80 ± 12.00 μm [min-max = 232-351 μm]; P = 0.012). There was a weak positive correlation between LCT and RNFL-inferior, RNFL-nasal, and RNFL-temporal. Conclusion: We found that the lamina cribrosa was thinner in MS patients with VEP pathology. To the best of our knowledge, this is a novel finding. Our results imply that LCT could be used as an indicator of optic neuritis in MS patients.
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Prognostic Significance of Magnetic Resonance Imaging in Detecting Diffuse Axonal Injuries: Analysis of Outcomes and Review of Literature p. 2371
Reddy Ravikanth, Pooja Majumdar
DOI:10.4103/0028-3886.364066  
Background: Diffuse axonal injury (DAI) is the brain injury characterized by extensive lesions in the white matter tracts over a widespread area. DAI is one of the most common and devastating types of traumatic brain injury and a major cause of unconsciousness and persistent vegetative state after head trauma. It occurs in about half of all cases with severe head trauma. Objective: This study was undertaken to evaluate the prognostic significance of magnetic resonance imaging (MRI) in detecting DAI and to determine which clinical factors provide prognostic information in patients with traumatic brain injuries. Materials and Methods: This prospective study was conducted in a tertiary care hospital between April 2017 to May 2019 on 52 patients admitted to the hospital with severe traumatic injuries of the head and clinical diagnosis of DAI. The clinical outcomes and findings of Thecomputerized tomography (CT)/magnetic resonance imaging (MRI) of the brain were assessed at 1 month, 3 months, 6 months, and 1 year on the basis of improvement in Glasgow Coma Scale (GCS), the time required to consciousness, and the duration of hospital stay. The patients were classified into three groups according to the MRI grading classification proposed by Adams. The outcomes at the 6 month follow-up time were dichotomized as non recovered (Glasgow Outcome Scale (GOS) score 1 or 2) or recovered (GOS score 3–5).The following factors were evaluated in relation to outcome: age, admission GCS score, the motor component of the GCS examination at admission and at 24 hours post admission, brainstem injury based on T2-weighted and gradient echo MRI sequences, presence of bilateral brainstem injuries, presence of DAIin the brainstem and the supra tentorial compartment (including the cortex, basal ganglia, and corpus callosum) on both CT and MRI, cerebral contusions, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and intraventricular hemorrhage. The statistical analysis was performed with x2 between various stages and between patients with and without hemorrhagic DAI. A separate analysis with x2 and Yates' correction was performed after grouping the patients with good recovery and moderate disability against patients with severe disability and vegetative state. Results: The correlation of patients GCS on admission, after 24 hours, and at discharge is statistically significant P < 0.001. Correlation among mean hospital stay in Grade I DAI, Grade II DAI, and Grade III DAI wass statistically significant (f = 70.22, P < 0.001). Correlation among mean time required for consciousness in Grade I DAI, Grade II DAI, and Grade III DAI was statistically significant (f = 181.92, P < 0.001). Based on anatomical location within the brainstem, the poorest outcomes occurred with injury to the medulla— with a 100% mortality rate. Poor outcomes were also associated with any injury to the pons. There was a significant correlation among brainstem injuries that crossed the midline, the motor component of the GCS examination, performed 24 hours after admission and at outcome. The median time to MRI was 1 day (range 0–35 days) among all, but 4 patients underwent MRI within 7 days after admission. Patients who did not recover underwent MRI at an average of 0.8 days after admission, whereas those who recovered underwent MRI at an average of 4.2 days after admission (P = 0.52). To determine if the time from admission to MRI had an influence on results, comparison was made between T2 and patient outcomes in relation to the interval between admission and MRI. Statistical analysis in the group of patients with different DAI stages showed a significant difference (P = 0.013). A statistically significant difference was also found between patients with hemorrhagic and non hemorrhagic DAI (P = 0.004). Conclusion: The current study showed a correlation between the mean time interval to recovery of consciousness in patients with DAI and the severity of injury grading on MRI. Hospital stay required for Grade I DAI was 2–3 weeks, for Grade II DAI was 3–4 weeks, and for Grade III DAI was 7–8 weeks. Apart from the well-known role of the Glasgow Coma Scale (GCS) in the prognosis of the outcome of patients with closed head injury, the presence of hemorrhage in DAI-type lesions and the association with traumatic space occupying lesions are additional poor prognostic signs established in this study. The analysis of outcomes were done for patients admitted with DAI and the current study established that poor outcomes were consistently seen in patients with brainstem injuries and poor results on 24-hour post admission GCS motor examinations.
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Triggering Receptor Expressed on Myeloid Cell-2 Protects PC12 Cells Injury by Inhibiting BV2 Microglial Activation p. 2378
Jian-Wu Ni, Cai-Xia Li, Xiong-Wei Chen, Wen-Pin Cai
DOI:10.4103/0028-3886.364080  
Microglia play a crucial role in the activation of immune defense mechanism as the resident macrophages in the central nervous system (CNS). Microglia can eliminate damaged neurons, plaques, and other infectious agents. Triggering receptor expressed on myeloid cell-2 (TREM-2) speculates to be beneficial in preventing inflammation-induced bystander damage of neurons. However, the precise molecular mechanisms underlying the regulation of TREM-2 on neurons are not clarified. We cultured PC12 cells with conditioned medium which was the supernatant of LPS-treated BV2 cells and six groups of PC12 cells (control group, LPS group, TREM-2 WT + LPS group, TREM-2 over-expression + LPS group, siRNA control + LPS group, and siRNA TREM-2 + LPS group) were investigated. The mRNA levels of inflammatory mediators: Nitric oxide synthase (iNOS) and Arginase-1(Arg-1) were quantified by using RT-PCR. Assessment of apoptosis in PC12 cells mediated by BV2 microglia was analyzed using TUNEL assays. The result showed that LPS stimulation significantly enhanced inducible iNOS (M1) production in BV2 cells (P < 0.01), and increased PC12 cells apoptosis (P < 0.01), while reduced the production of Arg-1 (M2) in BV2 cells (P < 0.01). These effects were attenuated by TREM-2 over-expression, but enhanced by TREM-2 silencing. It indicated that TREM-2 inhibited LPS-mediated neuronal apoptosis by down-regulating iNOS and up-regulating the expression of Arg-1 in BV2 microglia. Therefore, our findings may provide new insights in the regulation of TREM-2 on neuronal apoptosis via BV2 microglial M1/M2 modulation.
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Exposure to Toxocara Canis is not Associated with New-Onset Epilepsy p. 2383
Vivek Rishi, Rajveer Singh, Manoj Kumar Goyal, Manish Modi, Vivek Garg, JS Thakur, RK Sehgal, N Khandelwal, Gourav Jain, Amith S Kumar, Aditya Choudhary, Sudesh Prabhakar, Vivek Lal
DOI:10.4103/0028-3886.364076  
Purpose: The association between exposure to Toxocara canis and epilepsy is at the best contentious. Most of previous studies were retrospective, community-based, and contradictory to one another. As the impact of a positive association on the magnitude of epilepsy will be huge especially in developing countries where toxocariasis is common owing to poor hygienic practices, this study was carried out to determine whether exposure to T. canis predisposes to development of epilepsy. Patients and Methods: This case-controlled observational study was carried out a tertiary healthcare center in North India on 120 patients with newly diagnosed epilepsy who presented within 3 months of diagnosis. A total of 120 age- and sex-matched individuals from the same community were chosen as controls. Epilepsy was defined according to ILAE 1993 definition. Serological testing for T. canis was carried out using commercially available ELISA kits. All the positive samples were subjected to Western blot testing for confirmation. Results: The prevalence of antibodies to T. canis was similar in cases (16/120; 13.3%) and controls (16/120; 13.3%). Among the various risk factors, history of pica was significantly associated with T. canis seropositivity, while lack of hand washing was significantly associated with higher risk of epilepsy. Conclusion: Our study could not find any association between exposure to T. canis and epilepsy.
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Role of Multivoxel MR Spectroscopy Progressive Supranuclear Palsy – A Preliminary Study p. 2388
Sandhya Mangalore, Manoj Kumar, Pramod Pal, Jitender Saini, Shaik Pasha, Ravi Yadav
DOI:10.4103/0028-3886.364075  
Background: Progressive supranuclear palsy [PSP] is a neurodegenerative condition with characteristic clinical and imaging features. Aim: This is an exploratory MRS study to look at metabolic changes that occur due to the disease by using MR spectroscopic methods in subtypes of the PSP, that is, classic [PSP-c] and Parkinsonian [PSP-p]. Materials and Methods: A total of 12 PSPs subjects were included in this study, of which 8 subjects were clinically diagnosed as PSP-C and 4 subjects with PSP-P. We also included 6 healthy controls to compare metabolites between PSP groups. A multi-voxel MRS was performed using the Philips 3T MRI system, and postprocessing and metabolic peak fitting and quantification were performed using the Tarquin spectroscopic data-processing software. Individual patient MRS ratios of various metabolites were tabulated and analyzed to look for metabolic differences between these groups. Results: Significant differences were noted in various neurometabolites including GABA, Glutamate, Glutamine, Tau and NAA / creatinine ratio. Conclusion: Our preliminary findings indicate that MRS may act as an in vivo metabolic biomarker in various pathological conditions. Alteration and distribution of these metabolites may act as a marker for symptomatology and clinical presentation. MRS also has the potential for use in prognostic or in assessing the treatment response.
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Spectrum of Sensory Conduction Abnormalities in Guillain Barre Syndrome p. 2393
Madhu Nagappa, Rahul Wahatule, Parayil S Bindu, Sanjib Sinha, Arun B Taly
DOI:10.4103/0028-3886.364073  
Background: Sensory nerve conduction parameters in Guillain Barre Syndrome (GBS) are underemphasized. Objective: To describe abnormalities on sensory conduction studies in a large cohort of prospectively evaluated patients of GBS and to correlate with clinico-electrophysiological features. Methods and Materials: Sensory conduction parameters of three nerves (median, ulnar, and sural) were analyzed using standard protocols in 238 patients (M: F 163:75, mean age: 35.76 ± 15.9 years). Electrophysiological subtyping was based on criteria of Hadden et al., and Rajabally et al. Results: Among patients with “typical” GBS who underwent electrophysiological testing within 30 days of symptom-onset (n = 219), 183 (83.5%) had abnormal sensory potentials (one nerve = 52, two nerves = 77, all three nerves = 54). Frequency of abnormalities in sensory potentials increased with duration of illness. Commonest abnormality was reduced amplitude or in-excitable nerves. Mean amplitude and velocity of median and ulnar nerve sensory potentials were significantly lower among those with demyelinating electrophysiology (P < 0.05). Proportion of subjects with reduced amplitude and velocity of median and ulnar nerve sensory potentials was higher among those who required mechanical ventilation (P < 0.05). Frequency of “sural sparing” ranged from 10.5% to 84.5% depending on the criteria used and almost always was significantly associated with demyelinating neuropathy. Conclusion: This prospective study provides comprehensive data on sensory conduction parameters in GBS. Abnormalities are frequent and vary with duration of illness. While median nerve is most frequently and more severely affected, involvement of sural nerve may have prognostic value.
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Assessment of Relationship between Serum NT-proBNP Levels with Clinical Features and Prognosis in Acute Ischemic Stroke Patients p. 2401
Beyza Muhsine Arslan, Murat Cabalar, Nilgün Isiksacan, Vildan Yayla
DOI:10.4103/0028-3886.364072  
Background and Aims: We aimed to assess N-terminal pro brain-type natriuretic peptide (NT-proBNP) levels in acute ischemic stroke (AIS) patients according to clinical and radiological features and to investigate its relationship with short term clinical outcomes. Methods: In our study, 107 patients with AIS were evaluated prospectively. Of all, 56 patients had no evidence of atrial fibrillation (AF) (sinus rhythm [SR] group) (52.3%), 24 patients had paroxysmal AF (pAF group) (22.4%), and the other 27 patients had chronic AF (cAF group) (25.3%). Demographic datas, clinical characteristics, laboratory and radiological findings, CHA2DS2 -VASc scores, NIHSS (National Institute of Health Stroke Scale) and modified Rankin Scale (mRS) scores on admission and at the third month evaluations were recorded. Good functional outcome at 3 months was defined as modified Rankin score (mRS) 2 or less. According to the TOAST (Trial of Org 10172 in Acute StrokeTreatment) and OCSP (Oxfordshire Community Stroke Project) study, ischemic stroke subtyping was performed. Serum NT-proBNP levels were estimated in 107 stroke patients and 24 age- and sex-matched control subjects. Venous blood samples were obtained for serum NT-proBNP measurement within the first 48 hours of the patient group. Results: Mean age of the 107 AIS patients was 68 ± 15.22 years and 58.9% of them were women. Compared to controls, the SR, pAF and cAF groups had higher plasma NT-proBNP levels (P < 0.001) and also NT-proBNP values were significantly higher in the pAF and cAF group than SR groups (P < 0.001). NT-proBNP values were significantly higher in cardioembolic (CE) (n = 57) group than in large artery atherosclerosis (LAA) (n = 20) and small vessel disease (SVD) (n = 30) groups (P < 0.001). NT-proBNP levels of noncardioembolic SR (n = 49) (P = 0.080), LAA and SVD groups (P = 0.103) were higher than the control group but the difference was not statistically significant. There was a positive correlation between NT-proBNP level and third month mRS scores in CE group (r = 0.491). Conclusions: NT-proBNP will contribute to predict cardioembolic and pAF groups and estimate the prognosis.
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Fluoxetine or Venlafaxine for Early Post Stroke Depression p. 2407
Vivek K Nambiar, J Parvathy, Tania M Philip, K Abhijith, S Sreeni, Naveen K Panicker, Amrutha V Ajai, TS Dhanya
DOI:10.4103/0028-3886.364069  
Context: Post stroke depression (PSD) is an under diagnosed morbidity of stroke and can negatively affect the prognosis of the patient. Aims: We intended to study the prevalence of PSD and the commonly used anti-depressants and their outcome in patients with PSD. Settings and Design: A prospective observational study was conducted in the patients admitted to the stroke unit of a tertiary care centre. Methods and Materials: Diagnosis of post stroke depression was made by the Hamilton Depression Rating Scale (HDRS) during the two-week period after stroke or in the clinic follow up. A comparison of clinical outcome and adverse events of the two anti-depressants used, i.e. venlafaxine and fluoxetine were done by a follow up of up to 6 months. Statistical Analysis Used: Independent sample test was used for statistical purposes in the study Results: Out of the 326 stroke patients admitted in the department, 73 had PSD and 60 patients out of this were assigned into the study. Forty patients were males, and the mean age of the sample population was found to be 62.13 ± 11.14. Major risk factors identified were hypertension, diabetes mellitus, and dyslipidemia. Venlafaxine showed better outcome and less adverse events compared to fluoxetine. Major adverse events observed were hyponatremia, headache, insomnia, and anxiety. Conclusions: PSD in the early phase affects a substantial number of the stroke patients. Venlafaxine has got a better outcome and adverse event profile compared to fluoxetine in this group of patients. However, larger multicenter studies will provide more helpful data in this area.
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An Autopsy Study of Cerebrovascular Atherosclerosis in the Elderly p. 2411
Asha S Shenoy, Mayur N Bhosale, Gayathri P Amonkar
DOI:10.4103/0028-3886.364059  
Background: Stroke is an important cause of mortality with intracranial atherosclerosis as an important risk factor. Geographical variation in the pattern of atherosclerosis is well documented with various studies in stroke patients showing that African Americans and Japanese people tend to have intracranial vascular occlusion, whereas Caucasians more often have extracranial atherosclerotic lesions. Methods: This is a prospective study of 50 cases of Indian elderly patients over 60 years of age where we have studied the CNS vasculature in detail including intracranial atherosclerosis with regards to its incidence, severity, distribution, plaque composition and associated risk factors. We compared the atherosclerotic pathology in the intracranial vessels and the extracranial vessels including the carotids. Results: Out of 50 cases 31 showed intracranial atherosclerosis. Anterior circulation was more commonly affected. A total of 87 of the intracranial arteries showed atherosclerotic plaques, most common nature of the plaques being fibrofatty. Majority of the intracranial vessels showed mild stenosis and multiple vessels were involved in 15 cases while single vessel involvement was seen in 16 cases with the middle cerebral artery being the most common single vessel involvement. Infarcts were seen in 7 cases and all these cases had history of hypertension. Cerebral atrophy was seen in 28 cases. All cases showing frontoparietal and generalized atrophy had carotid artery stenosis. Of the 100 carotid arteries studied (2 per case) 59 showed atherosclerosis. Majority of the carotid arteries showed mild degree of atherosclerosis and the content was predominantly fatty. Conclusion: This study concludes that the pattern of atherosclerosis is different in the Indian population as compared to the western literature. Intracranial atherosclerosis is more common in Indian population with the anterior portion of circle of Willis being more commonly affected.
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Analysis of Neuromyelitis Optica Spectrum Disorder in an Indian Cohort using International Consensus Diagnostic Criteria p. 2416
G Gnanashanmugam, SP Somasundaram, N Parimalam, V Rajmohan, MB Pranesh
DOI:10.4103/0028-3886.364061  
Context: Updates on clinical, investigatory, and therapeutic aspects of neuromyelitis optica (NMO) spectrum disorders are rapidly evolving. Recently published international consensus diagnostic criteria (ICDC) allowed clinicians to rapidly diagnose the expanding spectrum of NMO spectrum disorders more accurately. Aims: The aim of the study was to retrospectively analyze 36 consecutive cases of comprehensively evaluated NMO spectrum disorders using the ICDC. Patients and Methods: We retrospectively collected 36 cases of NMO spectrum disorders who attended our unit between August 2012 andOctober 2016 and fulfilled the ICDC. All patients underwent magnetic resonance imaging (MRI) of the brain and whole spine with contrast, anti-aquaporin 4 antibody, and detailed blood investigations to rule out systemic vasculitis and other alternate diagnoses. Results: Female-to-male ratio was 6.2:1; 50% of the cases were in the 20–40-year age group. Six patients (16.67%) had combined optic neuritis and myelitis.Nine patients (25%) had pure longitudinally extending transverse myelitis LETM with positive anti aquaporin 4 antibody AQ4Ab. Fourteen patients (38.9%) had myelitis and optic neuritis separately. Nine patients (25%) had area postrema syndrome. Two patients (5.6%) had acute brainstem syndrome and one (2.8%) had hypothalamic syndrome. LETM was commonly found in the cervical level (69.4%).Four patients (11.1%) had no spinal cord involvement. Anti-aquaporin 4 antibody was positive only in 23 cases (63.9%). Conclusions: Initial presentation of NMO spectrum disorder is often due to brain lesions. The ICDC criteria have enhanced clinician's ability to diagnose NMO spectrum disorder in the early stages. In our study, ICDC criteria helped us to diagnose 33% additional cases that would have been missed if the old 2006 revised criteria was applied.
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Is Hypertrophic Pachymeningitis Really Idiopathic? p. 2422
Kamlesh Jagiasi, Prachi P Barvalia
DOI:10.4103/0028-3886.364052  
Background: Hypertrophic pachymeningitis (HPM) is a unique disorder characterized by thickening and fibrosis of the dura mater. Clinically it presents with headache, cranial nerve palsies, and other focal neurological deficits. Two forms exist, one is primary, where all other causes have been excluded and the other is secondary where an identifiable cause exists. It is important to recognize these secondary causes as treatment depends on the etiology. Objective: To elucidate the various characteristics of HPM. To delineate clinical-radiological features that help differentiate secondary from primary causes and to understand treatment response and disease outcomes of HPM. Methods: This retrospective observational study included 33 patients who presented with radiological diagnosis of HPM from January 2014 to July 2019. Spontaneous intracranial hypotension patients were excluded. All patients were extensively evaluated for secondary causes and treatment outcomes were analyzed on follow-up. Results and Conclusions: Secondary causes of HPM were present in 48% cases. The clue for primary causes is an associated Tolosa-Hunt syndrome. Secondary causes in our series are immunological, infection, and malignancy. Clues to differentiate primary from these secondary causes are clinical like myelopathy, seizures, poor response to immunosuppression; radiological like hypertrophic cranial nerves, infarcts, bony erosion, and leptomeningeal involvement. There are case reports in literature but large Indian studies are lacking. This manuscript presents a large cohort of cases with HPM, which helps differentiate primary from secondary causes, as management and prognosis depend on etiology. An algorithm depicting the approach to the management of HPM has been presented.
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Impact of Thymectomy on Crisis Incidence and Quality of Life amongst Generalised Myasthenia Gravis Patients p. 2427
Meena A Kanikannan, Pavan K Reddy, Neeharika L Mathukumalli, Sireesha Yareeda, Rupam Borgohain
DOI:10.4103/0028-3886.364067  
Background: Thymectomy, combined with corticosteroids, immunosuppressive agents, and cholinesterase inhibitors, has been accepted as the standard treatment for myasthenia gravis (MG) patients. Data on the effect of thymectomy on occurrence of myasthenic crisis are few. Objectives: To assess the long-term impact of thymectomy in patients with generalized Myasthenia gravis (GMG) in terms of occurrence of myasthenia crisis and quality of life. Methods: A retrospective analysis of 274 clinical records of patients diagnosed with myasthenia gravis (MG) in Nizam's institute of medical sciences (NIMS), a tertiary level teaching hospital between January 2000 and December 2015 was done. Severity of the disease was assessed using Myasthenia Gravis Foundation of America (MGFA) classification and quantitative myasthenia gravis (QMG) score. Myasthenia crisis was diagnosed in our patients when they required ventilator assistance due to respiratory failure caused by muscle weakness (MGFA class V). Quality of life (QoL) was assessed. Results: Of 230 cases included in the final analysis, 108 (46.9%) underwent thymectomy. Posttreatment crisis occurred in 53.3% of the nonthymectomy subjects, and 25.9% of thymectomy group (P < 0.001). In multivariate logistic regression analysis, after controlling for the effect of gender, age at diagnosis and grade of the disease, the odds ratio of myasthenic crisis in people with thymectomy was 0.186.(95% CI 0.087 to 0.387, P = 0.001). No statistically significant differences were observed in quality of life scores between thymectomy and nonthymectomy groups, either before (P = 0.86) or after surgery (P = 0.939). Conclusions: The odds of myasthenia crisis was lesser in people, who underwent thymectomy even after controlling for MGFA grade and other potential confounders but no significant differences in quality of life were found with thymectomy.
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INDIAN PERSPECTIVE Top

COVID-19 Pandemic Lockdown: A Cloud with a Silver Lining for the Road Traffic Accidents Pandemic p. 2432
Debabrata Sahana, Lavlesh Rathore, Sanjeev Kumar, Rajiv K Sahu, Amit K Jain, Manish K Tawari, Pravin R Borde
DOI:10.4103/0028-3886.364053  
Context: Effects of coronavirus disease 2019 (COVID-19) pandemic lockdown on road traffic accidents (RTAs) in Chhattisgarh, India. Background: Most neurosurgical emergencies are from brain and spine trauma. RTA is the leading cause of such injuries. While the nationwide lockdown was an extreme measure to control the COVID pandemic, it influenced the overall road traffic dynamics and neurotrauma. Objective: This study aims to assess the impact of the lockdown on neurotrauma. Methods and Materials: This retrospective study included all patients with brain and spine injuries who were admitted between January 17th and May 31st, 2020. The study population was divided into prelockdown (PL) and lockdown (L) groups. Results: Of the 668 patients, 436 were placed in the PL and 232 in the L group. The mean ages were 36.34 (SD = 17.96) and 35.98 (SD = 16.93), respectively. Male to female ratios were 82.3:17.7 in the PL group and 79.7:20.3 for the L group. RTA-related injuries were significantly lower during the lockdown period (n = 335 PL vs. 162 L [P = 0.048]). During the lockdown, there were more mild injuries (25.91% PL vs. 36.63% L) and less severe injuries (33.25% PL vs. 18.96% L [P = 0.0002]). Mortality was significantly less (P = 0.029) during the lockdown (n = 48 L vs. 124 PL). The proportion of RTA-related neurotrauma cases increased (33.33% L1, 57.14% L2, 73.13% L3, and 80.39% L4) with each phase of lockdown (L1-L4). Conclusions: During the lockdown period, the number of trauma cases had decreased, with a significant decrease in RTA-related admissions, along with their severity and mortality. The number of trauma cases and their severity increased gradually with each phase of lockdown.
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CASE REPORTS Top

Van Der Knaap Disease: Young Male with Megalencephalic Leukoencephalopathy with Subcortical Cysts: A Case Report p. 2437
H Kaushal, H Khutan, H Sood, K Shourya, Z Mahendru
DOI:10.4103/0028-3886.364064  
Van der Knaap leukoencephalopathy (Megalencephalic leukoencephalopathy with subcortical cysts) is an autosomal recessive disorder of macrocephaly and neurological deficit. Magnetic resonance imaging (MRI) and clinical features are certainly helpful for determining the characteristic findings and distinguishing it from other diseases of similar presentation.
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Is Diffusion-Weighted-Image (DWI) Sequence Reliable in Acute Large Vessel Hemispheric Ischemic Infarction? p. 2440
Sang Bin Hong, Young-Seok Lee
DOI:10.4103/0028-3886.364062  
The appearance of restricted-diffusion on the diffusion-weighted image (DWI) sequence is a reliable radiologic marker in acute ischemic stroke. Exceptions may occur in small brainstem strokes shortly after symptom onset. Three large hemispheric stroke cases with clinical symptoms lasting hours without any or only subtle DWI changes are identified over six years by the senior author. Even large hemispheric ischemic strokes with symptoms lasting hours may not reveal definitive DWI signal changes. Recognition and characterization of diffusion-negative large hemispheric stroke cases are important since this period represents a window of opportunity for acute medical treatment and/or neuro-intervention.
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Cerebral Venous Sinus Thrombosis with Bilateral Inverse Duane's Retraction Syndrome—A Case Report p. 2443
Devavrat H Nene, Ravi Yadav
DOI:10.4103/0028-3886.364070  
Background: Cerebral venous sinus thrombosis (CVST) is a life-threatening condition with a predilection for a younger age group. Patients with CVST can have features of raised intracranial pressure that can be suspected clinically based on ophthalmological findings such as bilateral abduction restriction, papilledema. Case Description: A 27-year-old gentleman presented with 15 days history of headache and seizures with complete abduction restriction of both eyes along with retraction of globe and narrowing of palpebral fissure on abduction. His MRI brain showed superior sagittal sinus thrombosis without any parenchymal lesion. Conclusion: The final diagnosis in our case was bilateral inverse Duane's retraction syndrome with CVST, a co-occurrence that has not been reported in the past and can be missed if the eye movements are attributed to raised intracranial pressure alone.
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External Capsular Hyperintensities in Wilson's Disease Presenting with Refractory Status Epilepticus p. 2446
Tandon Ruchika, Mittal Madhukar, K Goyal Abhishek
DOI:10.4103/0028-3886.364078  
Wilson's disease is a genetic disorder characterized by abnormal accumulation of copper in the brain, liver, eye, and kidney. Various neuropsychiatric manifestations such as dystonia, parkinsonism, choreoathetosis, tremor, ataxia, personality disorders, mood changes, psychosis, cognitive abnormalities, sleep disorders, dystonia, tremor, ataxia, and seizures are known to occur in Wilson's disease. Status epilepticus is a very rare presentation of this disease. Here, we present a case of Wilson's disease occurring in an adolescent, who presented with refractory convulsive status epilepticus. His magnetic resonance imaging of the brain showed bilateral external capsular hyper intensities, with only subtle changes in other brain areas and the only clue to the presence of Wilson's disease was the presence of mildly deranged hepatic enzymes. The 24-h-urinary copper levels were subsequently found to be elevated in this patient.
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Posterior Reversible Encephalopathy Syndrome Complicating the Postoperative Clinical Course in a Child with a Suprasellar Craniopharyngioma p. 2449
Akhil Sunil, Saritha Aryan, Sumit Thakar, Alangar S Hegde
DOI:10.4103/0028-3886.364065  
Posterior reversible encephalopathy syndrome (PRES) is an unusual neurological condition known to occur in the setting of various risk factors such as acute hypertension, renal failure, sepsis, multiorgan failure, autoimmune disease, and immunosuppression. Twenty cases of PRES have been previously reported in neurosurgical literature, almost all of which were attributed to either hypertension or chemotherapeutic drugs. Herein, we report a case of PRES in a neurosurgical patient in the absence of the commonly described risk factors for the syndrome. The patient was a 9-year-old boy who underwent uneventful transcranial resection of a suprasellar craniopharyngioma. His postoperative clinical course was complicated by hepatic failure and hypothalamic dysfunction, both of which were managed conservatively. Ten days after the onset of these complications, he developed clinical and radiological features suggestive of PRES which eventually resolved at follow-up. We discuss the pathogenesis of this unusual neurological syndrome in our patient in the light of a literature review.
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LETTERS TO EDITOR Top

Sphenopalatine Ganglion Block for the Treatment of Severe Headache following a Ruptured Aneurysm p. 2452
Shalendra Singh, Javed Iqbal, Nikahat Jahan, Rahul Yadav
DOI:10.4103/0028-3886.364060  
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Internal Carotid Artery Injury in Clinoidal Meningioma Surgery: Reflections from a Complicated Case p. 2454
Kuntal K Das, TP Waseem, Awadhesh K Jaiswal
DOI:10.4103/0028-3886.364054  
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Role of Magnetic Resonance Imaging (MRI) in the Etiological Diagnosis of Neonatal Seizures: A Prospective Observational Study p. 2456
Srivijayalakshmi Ravichandran, Balakrishnan Rajaiah, Rajendran Karupanan, Thangaraj Abiramalatha, Kannan Gunasekaran, Shriram Varadharajan, Srinivas Ramakrishnan
DOI:10.4103/0028-3886.364063  
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Worm in the Brain: A Case of CNS Gnathostomiasis p. 2458
Arun Gokul Pon, AV R Taallapalli, Haripriya Krishna Reddy, Saraswati Nashi, Sandhya Mangalore, PR Srijithesh, Girish Baburao Kulkarni, Suvarna Alladi, Paron Dekumyoy
DOI:10.4103/0028-3886.364071  
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NEUROIMAGES Top

Conus-Cauda Syndrome in a Patient with Burkitt Leukemia p. 2461
Saniya Sharma, Rajeev Sandal, Sreejesh Sreedharanunni, Gaurav Prakash, Vivek Gupta
DOI:10.4103/0028-3886.364056  
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A Concomitant Sincipital Encephalocele in a case of Idiopathic Intracranial Hypertension p. 2463
Ping H Lau, Hasyma Abu Hassan
DOI:10.4103/0028-3886.364055  
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Sneddon Syndrome p. 2465
Gioppo Andrea, Scelzo Emma, Bersano Anna, Faragò Giuseppe
DOI:10.4103/0028-3886.364083  
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An Ancient Schwannoma of the Radial Nerve-Rare Case p. 2467
Jayabal Pandiaraja, Arumugam Shalini
DOI:10.4103/0028-3886.364058  
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OBITUARY Top

In Memorium: Prof AK Banerjee MD, FAMS, FRCPath (July 23, 1939 – July 31, 2022) p. 2469
Bishan Radotra
DOI:10.4103/0028-3886.359353  
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ERRATUM Top

Erratum: Prof Ravi Marthanda Varma - A Visionary par Excellence p. 2471

DOI:10.4103/0028-3886.364209  
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